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Purpose: The aim of this study was to demonstrate surgical pearls in big-bubble deep anterior lamellar keratoplasty using a modified Miyake–Apple camera system and to correlate these findings with histology.

Methods: This was a wet laboratory-based pilot study. Cadaveric human corneal tissue consented for research and not suitable for transplantation was fixed to a glass slide and assembled into the modified Miyake–Apple camera system. Dissections were performed and recorded. Selected specimens were submitted for light microscopy.

Results: Key points illustrated by video analysis included the entry of air into the artificial anterior chamber through the trabecular meshwork without Descemet membrane perforation, the contrast of this event with frank perforation, the potential of viscoelastic injection as a salvage maneuver, and the modes of air passage during the procedure. Histological correlation confirmed the air passage through the trabecular meshwork and demonstrated the appearance of pneumatized corneal stroma in the setting of a failed big-bubble and corneal “white-out.”

Conclusions: We present the video analysis that correlated with the histology of air behavior during big-bubble deep anterior lamellar keratoplasty. The chief points illustrated include signs associated with air entry into the eye in the presence and absence of Descemet perforation.

*Division of Cornea and External Disease, Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada;

S. P. Holland has received research support from Alcon Laboratories Inc and received travel support from Allergan and Bausch & Lomb. The other authors have no funding or conflicts of interest to disclose.

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